Provider Demographics
NPI:1912002668
Name:MAIWALD, DIANE CECILE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:CECILE
Last Name:MAIWALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 OAKWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746
Mailing Address - Country:US
Mailing Address - Phone:631-423-2110
Mailing Address - Fax:631-423-8672
Practice Address - Street 1:284 OAKWOOD ROAD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746
Practice Address - Country:US
Practice Address - Phone:631-423-2110
Practice Address - Fax:631-423-8672
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170366207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
11E851Medicare ID - Type Unspecified
A60558Medicare UPIN